Health

HE A LTH • Fall 2019 9 "It's prescribed to be low-cost," he said. Costs were a major driver from the start for such ambulatory surgery centers – known in the industry as ASCs – according to David E. Williams, the president of the Boston consulting firm Health Business Group. Physicians found the centers could be highly profitable to own and run, with higher-margin specialties like orthopedic and cardiac operations and patients who more likely carried private insurance, Williams said. Outpatient centers don't have higher- cost burdens coming with keeping patients overnight or needing to be able to handle any type of medical need. "They weren't started for patient comfort and satisfaction," Williams said. In more recent years, ASCs have begun handling operations in sports medicine such as anterior cruciate ligament, or ACL, reconstruction. In some outpatient facilities, joint replacement surgeries are even taking place, something leaders at the Surgery Center in Shrewsbury expect will become more widespread. Two-thirds of operations now take place on an outpatient basis, according to the American Hospital Association. At the same time, the number of national inpatient admissions has fallen since a decade ago, and outpatient hospital revenue – as low as 30% of overall revenue in 1995 – nearly matched inpatient revenue in 2017, according to the association's latest data. Nationally, more than 6,100 ambulatory surgery centers are now open, according to the Ireland market intelligence firm Research and Markets. "Nationwide, the number of ASCs that have sprouted up is phenomenal," said Dr. Thomas Breen, an orthopedic surgeon at UMass Memorial who works at the Surgery Center in Shrewsbury. "Because of the outpatient setting, it's a much more pleasant experience for the patient. It's not that big-hospital atmosphere." Growth in Central Mass. and elsewhere More such surgical centers are likely on the horizon, locally and nationally, thanks in large part to an aging population whose procedures can more often take place away from a hospital campus. Research and Markets projects a 16% increase in the number of procedures from 2016 to 2026. Global Market Insights Inc. in Delaware, citing rising rates of cardiovascular, diabetes, arthritis and other health issues, is projecting revenue from such centers to rise from $70 billion in 2018 to around $95 billion by 2025. Williams expects continuing growth, thanks to a series of trends: Patients looking for joint replacements at younger ages, when they're generally in better shape to be operated on in an outpatient setting, and the popularity of such centers with both patients and physicians. AARP, the Washington, D.C. group for older Americans, projects knee and hip replacements to grow by more than 170% by 2030. Between 2000 and 2014, the mean age of patients for hip replacement surgery fell from 66.3 years to 64.9, and the median age of knee replacement patients dropped from 68 years to 65.9, according to the group. The industry publication Becker's ASC Review has said it projects far more gynecology procedures to take place on an outpatient basis. Massachusetts would seem to have plenty of room to grow in the number of ASCs, with 55 as of June 2018, according to the Ambulatory Surgery Center Association's count of Medicare-certified centers. Maryland, which has a slightly smaller population, has 346, and many Southern states with fewer people also outnumber Massachusetts. Reliant, which provides outpatient surgery at other centers, is planning with Shields an ambulatory surgery center slated to open next year in Natick. The Natick Surgery Center will offer surgical services including orthopedics, gynecology, urology, general and vascular surgery, and ear, nose and throat operations. The $10-million Natick facility will be built in an existing office building at 313 Speen St. across from the Natick Mall, with three outpatient operating rooms, along with pre-operative, a post-anesthesia care unit and other spaces. The Massachusetts Department of Public Health approved the center in June. A third partner in the Natick facility is ASC Holding Co., a firm representing community-based orthopedic specialty physicians. In other cases, health providers have been shifting services to new areas. Last winter, UMass Memorial opened a 120-bed mental health care facility, Hospital for Behavioral Medicine, in Worcester, replacing some beds that were located on hospital campuses. In April, MetroWest Medical Center opened an outpatient maternity care unit for labor assessment, lactation support and other services pre- and post-partum. H Hospital surgeries The Surgery Center, which opened in Shrewsbury in May 2018, brought together three healthcare providers in the latest expansion of outpatient medical procedures. Outpatient operations have risen among community hospitals nationally over the last two decades, while inpatient operations have fallen. Source: American Hospital Association (2018) Outpatient Inpatient Year operations operations 1996 14,023,651 9,545,612 1997 14,678,290 9,509,081 1998 15,593,614 9,735,705 1999 15,845,492 9,539,593 2000 16,383,374 9,729,336 2001 16,684,726 9,779,583 2002 17,361,176 10,105,010 2003 17,165,616 9,940,922 2004 17,351,490 10,050,346 2005 17,445,587 10,097,271 2006 17,235,141 10,095,683 2007 17,146,334 10,189,630 Outpatient Inpatient Year operations operations 2008 17,354,282 10,105,980 2009 17,357,534 10,100,980 2010 17,357,177 9,954,821 2011 17,269,245 9,638,467 2012 17,297,633 9,513,598 2013 17,418,773 9,147,264 2014 17,386,061 9,015,467 2015 17,588,335 8,920,775 2016 18,224,816 8,982,309 Percent change Amanda Connor, a nurse at the Surgery Center in Shrewsbury, checks with a recovering patient in one of 32 bays at the facility where patients can prepare for and recover from operations. -5.9% 30.0%

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